The Surgery Process

The transplant operation itself can be conceptualized as consisting of the hepatectomy (liver removal) phase, the anhepatic (no liver) phase, and the postimplantation phase. The operation is done through a large incision in the upper abdomen. The hepatectomy involves division of all ligaments from the liver, as well as the common bile duct, hepatic artery, hepatic vein and portal vein. Usually, the gallbladder is removed along with the liver.

The donor's blood in the liver will be replaced by an ice-cold organ storage solution, such as UW (Viaspan) or HTK until the new liver is implanted. Implantation involves connections of the inferior vena cava, portal vein and hepatic artery. After blood flow is restored to the new liver, the bile duct is reconnected, either to the recipient's own bile duct or to the small intestine if the gallbladder has been removed. The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon.

The large majority of liver transplants use the entire liver from a deceased donor for the transplant, particularly for adult recipients. A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child. Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients, and living donor liver transplantation, in which a portion of a healthy person's liver is removed and used as the donor liver. Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver.

The incision on the belly is in the shape of an upside-down Y. Some people compare it to the logo of the car manufacturer Mercedes. Small, plastic, bulb-shaped drains are placed near the incision to drain blood and fluid from around the liver. These are called Jackson-Pratt (JP) drains and may remain in place for several days until the drainage significantly decreases. There are two different ways to connect the bile duct to the intestine, depending on the liver disease of the patient. The first way is connecting the patient's own bile duct to the donor bile duct. If this is done, a small tube called a T-tube, is placed between the bile duct connections. The tube will then exit through the skin but is easily concealed by clothing. This allows the team to monitor the amount and consistency of bile being made by the liver. This tube is tied off within the first week and removed six months after transplantation. The second way to connect the bile duct to the intestine is used if a patient's own bile duct is diseased. In this situation, the new bile duct will be connected with the patient's intestine. A small tube called a stent, is placed at the connection site. It later falls out of the duct on its own and is passed in the stool sometime after the operation.

If the gallbladder was not removed, there is a possibility that gallstones may form and cause problems with the new liver. The gallbladder is a small muscular pouch that is a storage organ for bile. Bile is made by the liver and excreted into the bile duct. The bile duct is a tube that carries the bile to the gallbladder and then to the intestinal tract. The gallbladder is stimulated to squeeze a large amount of bile into the bile duct by fat in the diet. Bile mixes with the ingested food and helps with digestion. If the gallbladder is removed, the liver will release bile directly into the intestines when it is stimulated by food or other substances. Few people notice any symptoms after removal of the gallbladder.

The final step of the operation is to close the abdomen. This is done with several layers of sutures and the skin being closed with staples. The closures take about one hour.

During the surgery, an operating room nurse will be periodically calling your family with an update. If the family will not be in the waiting area, it is important to leave a contact number with the operating staff.

After surgery, the patient is taken to an intensive care unit where he/she is monitored very closely with several machines before moving to the transplant unit. The patient will be on a respirator, a machine that breathes for the patient, and will have a tube in the trachea (the body's natural breathing tube) bringing oxygen to the lungs. Once the patient wakes up enough and can breathe alone, the tube and respirator are removed.

The patient will have several blood tests, x-rays films, and ECGs during the hospital stay. Blood transfusions may be necessary. The patient leaves the intensive care unit once he or she is fully awake, able to breathe effectively and has normal temperature, blood pressure and pulse—usually after about 1-2 days. The patient is then moved to the transplant unit with fewer monitoring devices.

Once on the transplant unit, activity and diet are normalized as quickly as possible. Diet advances from clear liquids to no-added-salt diet as soon as a patient is able to tolerate solid foods. You will be encouraged to be out of bed and active as much as possible and physical therapy will be initiated to help with activity. The average stay in the hospital following liver transplantation is about two weeks.